Why Cigna Denies Home Health Services
Patient is not homebound
Skilled need not documented
Services exceed reasonable frequency
Know Cigna / Evernorth's Criteria
Cigna uses their own Coverage Policies and InterQual criteria. Medical directors are generally accessible for P2P review.
Key policies to know:
- Coverage Policies available on cigna.com/coverage-policies
- Uses eviCore for specialty benefits management
- Known for step therapy requirements on specialty drugs
- Collaborative care approach with emphasis on outcomes data
Building Your Medical Necessity Argument
Document homebound status with specific functional limitations
Define the skilled need (wound care, medication management, PT/OT)
Note why outpatient services are not feasible
Reference recent hospitalization or change in condition
P2P Call Tips for Cigna
Reference Cigna Coverage Policy by number
Cigna medical directors tend to be collaborative -- frame it as shared decision-making
Emphasize outcomes data and evidence-based medicine
Be prepared to discuss alternatives and why they were insufficient
Guidelines to Reference
- CMS Home Health Coverage Requirements
- Medicare Benefit Policy Manual Ch. 7
Relevant CPT Codes
Specialty: Internal Medicine / Family Medicine
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